How to Say "No" When Your Client Says "Yes," Part III

By Ruth Werner, LMP, NCTMB, Massage Therapy Foundation President

Author's note: since this article was written, our lives have been changed forever. For all the people who lost friends or loved ones in the terrible events of September 11, 2001, my heart goes out to you.

Words are useless, but prayers are unceasing.

Greetings, Readers:

In my August 2001 column, we began to look at the delicate conversation that must occur when a bodyworker observes some sign that renders planned type of session impractical, or even potentially hazardous. What do you do? What do you say? Here's a basic formula:

State your observations.

State your concerns.

State your choices.

These three steps can frame most difficult conversations with clients about anything, from an undiagnosed skin rash to chronic lateness. (This column is dedicated to discussing the role of massage in the context of disease and illness, however, so that's what we'll focus on here.) This formula can allow therapists to be kind, compassionate, caring people, who are still allowed to have boundaries for safety and professionalism.

As promised in my last article, here are some further guidelines that should flavor this difficult conversation:

Remember, this choice is for the client's benefit above all.

Acknowledge your scope of practice: "I am not a doctor, and I cannot diagnose what this situation is, but I have some concerns..."

Do your best to keep personal judgments out of the conversation.

Listen to, and seek to understand, your client's reaction. He or she may react with anger, fear, embarrassment, curiosity, resentment, etc. How would you react to hearing the same thing?

Respect your own boundaries for client (and therapist) safety. Although the client is in a sense your employer, you decide whether it's a good idea to work together. If you have the choice to keep the client safe vs. giving in to the client's poor judgment, safety is more important.

No one looks forward to these conversations, and no one thinks they're easy. But as the number of people seeking massage increases, the possibility of seeing someone with a serious condition gets greater and greater.

Here is a case in point, from one reader:

This case was a man in his 50s who I had seen many times before. At this session, he complained of having continuous pain in the right lower quadrant of his abdomen for two days. I asked him if he had seen a physician. He said he had gone to the ER the night before; they had given him an antacid and sent him home. I asked him to lift his right leg. It caused him additional pain. He said it hurt him at each step. My mental red flags went up the pole. I stopped the massage, told him, "I think you may have an inflamed appendix," and advised that he get to his primary physician as quickly as possible. He did this, and his appendix was removed a few hours later.

It is quite possible that the therapist saved this man's life; appendicitis is notoriously hard to diagnose, but she recognized some important signals and terminated the session, so that he could seek the appropriate help.

Here's another example, from Wayne in Palm Springs:

I was working at a hotel in the Palm Springs, California area several years ago, where companies sometimes booked massages for their employees. This lady came in to my massage room; she looked awful. I said, "Are you OK?" She said, "No, I feel terrible; but the company said I had to get a massage, so I came."

I said, "No, you don't have to get a massage. In fact, you look like you have a fever, and I wouldn't work on you anyway." (I didn't say this in a mean tone, but gently).

She said "Oh, thank you, I'm so glad you said I don't have to get the massage - thank you!" And she left.

I thought, what a blessing to give someone relief by not giving a massage!

These stories illustrate how close we are all the time to accidentally doing harm, even with the best of intentions. I've received other letters about working with clients who didn't share some important information on their intake forms, or clients who refused to fill out intake forms at all, and other circumstances that made doing massage as a career sound much more exciting than most of us probably planned on!

This issue of "How to say 'No'" seems to have hit a chord with many therapists, and it seems important to keep exploring it. For next time, I have two things I'd like to address:

I'd like to hear how you've responded to clients who hid some important information from you until they were on the table. How did you respond? Do you think you responded well? Would you do it differently next time?

Does anyone out there have any experience working with clients who have shunts to drain excessive cerebrospinal fluid? I received this letter from Sharon in Newark, Delaware:

I have a client who, after having a brain tumor removed - some rare condition I don't remember the name of - developed fluid buildup. Now she has a shunt in the left side of her brain, draining into her abdomen. I have checked several massage reference books but I didn't find anything regarding this condition. I realize I am not supposed to do massage directly over the area, but what is the best protocol to follow when giving this client a massage?

I have no useful advice to offer Sharon, except that which she had already planned to do: consult with this client's health care team. But since this newsletter goes out to some 95,000 therapists, it seems likely that some of you might have had experience with clients in this situation. Do you have anything you'd like to offer Sharon, or other massage therapists working with clients who have shunts? Thanks in advance for your input!

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